Hospital Dr News

Human Factors training to be rolled out for GMC investigators following Bawa-Garba case

The GMC’s fitness to practise decision makers, case examiners and clinical experts are to receive ‘human factors’ training, and advice on modifying investigation processes.

The GMC’s Fitness to Practise directorate investigates complaints or concerns about doctors which raise a risk to patients or public confidence in the wider profession.

The work paves the way for the GMC to draw on human factors experts when it chooses to investigate doctors, and where systems issues need to be better understood in order to do so.

The GMC is working in partnership with Oxford University’s Patient Safety Academy team.

Human factors is a social science which studies and attempts to optimise the interactions of humans, technology and the environment at work.

It is a standard tool of safety investigation and improvement in several industries such as civil aviation, nuclear power and military planning which seek to balance high risk and high reliability.

In future the GMC is aiming to work with Responsible Officers to ensure that the same approaches are also consistently applied locally when they are dealing with concerns around doctors’ conduct and performance, before those issues are referred to the GMC.

Charlie Massey, Chief Executive and Registrar of the GMC, said: “This collaboration will make sure that Human Factors are hardwired into our investigations so that the role systems and workplaces play in events is fully and evenly evaluated in assessing context following serious failings.

“That will guarantee consistency in how we investigate after things have gone wrong and give doctors the assurance that their actions will be seen clearly against the backdrop of any system failings.”

The GMC faced significant criticism over the Bawa-Garba case, in which an individual junior doctor was pursued in the High Court on a charge of gross negligence manslaughter over the tragic death of a boy in hospital.

Commenting on the human factors training, Dr Caroline Fryar, head of advisory services at the MDU, said: “We welcome this acknowledgement by the GMC that in order to ensure their investigations are fair and balanced, they take into account system failures, when investigating individual doctors.

“As we have seen in the recent high profile cases of doctors prosecuted for gross negligence manslaughter, clinicians can be held individually accountable for tragic incidents in which system errors also played a part.

“Doctors are often required to make decisions and take action or decide to take no action in circumstances over which they have no control and are far from ideal. For example, they may be short-staffed and trying to do the job or two or more colleagues while juggling the care of seriously ill patients.

“We are glad that the GMC is recognising and taking into account the fact that doctors are often put in a position where they are unable to control their environment and circumstances but must carry on and treat patients as best as they can.”

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